Friday, August 11, 2006
When Nurses Attack
Maybe six months after I arrived in town, I was referred a patient with cancer of the distal esophagus. The perversity of being a surgeon is that despite the terribleness of the disease, it's hard not to be excited about the prospect of doing the operation to (hopefully) cure it. If you like doing general surgery, esophagogastrectomy pretty much has it all: the blue-plate special. First, you lay the patient on his back, and open his belly. Then you cut loose the stomach from all its attachments, tying off many many vessels, peeling it off the pancreas, separating it from the liver the colon, until it's hanging like a hammock in the breeze, suspended between the duodenum and the esophageal hiatus. You may or may not remove the spleen. If you're smart, you'll insert a feeding tube into the intestine (in case there are post op swallowing or other difficulties). I always did a very short pyloroplasty (slightly controversial: it's to prevent food from backing up in the partially defunctionalized stomach. If you make it too big, there can be a "dumping syndrome." Never saw it with a minimalist cut.)Then you sew up the abdomen and roll the patient onto his left side, after which you slash open the right chest, between the ribs. After entering the chest cavity and loosening up the lung, you dissect free the lower half of the esophagus, up to the azygous vein; then you pull the free stomach into the chest. Including the tumor in the middle, you remove the lower portion of the esophagus along with the upper portion of the stomach, and drop the sizeable chunk of tissue into a bucket for the pathologist. Then you attach the remaining esophagus to the remaining stomach and fashion a sort of collar of stomach around the anastomosis, to prevent reflux. Leaving a couple of chest tubes, you reapproximate the ribs and sew everything up.
The man was in his early 50s; a smoker (aren't they all?) but otherwise quite healthy. I explained the situation, and he agreed. What choice did he have, really?
The operation went perfectly; in fact, I think everyone in the OR was impressed. New kid in town, tackling a big operation with aplomb and dispatch. In the recovery room, the patient was stable as could be. But a two-cavity (as we like to say) operation takes a lot out of a person (no pun) and many postop difficulties are possible. Fluid shifts, heart and lung problems, pain management. I admitted him to the ICU, where I hung around for awhile, then went home assured he was doing great. My sleep was untroubled.
Until around three a.m., when the phone rang. Without any preliminary pleasantries, the nurse on the other end said "Mr. D's CVP is zero." I waited a beat, assuming there might be more info forthcoming. None. So I asked "How's his blood pressure?"
"120 over 80." (Note: perfect.) Pause, silence.
"What's his pulse?"
"76, regular." (Note: perfect.) Pause. Silence.
"OK, how much urine is he making?"
"50 - 60 cc an hour." (Note: perfect.) Pause. Silence.
"Does he have a fever?"
"So, how's his mental status?"
"He's reading a magazine."
"Well, uh, how's his oxygenation?"
"Last blood gas was fine." (Didn't have continuous oxygen monitoring in those days.) Pause. Silence.
"Gee, it sounds like he's doing great," I said. "
"A CVP of zero isn't normal," I was informed.
"Yeah, but it's really a relative number. Sounds like his volume is just fine." This was also before continuous readouts of CVP: to measure it, the patient was laid flat, a tube was filled with saline, held vertically (by eyeball) at a (hopefully) previously marked point on the neck, and the fluid was allowed to run into the patient. The point at which it stopped, in terms of centimeters above the marked point, was considered the CVP.
"You mean you're not going to do anything about it?"
"Well, really, it seems to me......" At that point I was talking to a dial tone.
What the hell just happened? The guy's fine. It's not like I'd been told his blood pressure was sixty and I'd said to give him an aspirin. Was it that her experience told her esophagogastrectomy patients don't do that well? (The surgeon in town who did most of them was, well, a bit brutal.) Was it just that she didn't know me? Was I guilty of operating a knife while young? Going back to sleep was impossible but I sure as hell wasn't going to go in to see a patient doing perfectly. I showed up, as usual, at 6 a.m.
A nurse I'd never seen before strode up to me quite purposefully. "Are you Dr Schwab," she asked (accused, really.) "Yes," I said, " and I'd like to talk......" The sentence trailed off as she turned and huffed out the door, as if I'd flashed her, or used the worst insult in my lexicon. Meanwhile, the only way in which my patient's status had changed is that he was now reading the morning newspaper. I sought out the head nurse. She seemed already to know what had gone on. "Geez," I said. "It's not like I ignored the guy. Look at him -- he looks like a damn visitor." The head nurse looked me in the eye and said, slowly, deliberately, with pained forbearance: "Our EVERETT physicians would have DONE something about a CVP of zero."
I was the ventriloquist's dummy, hand up my rear, mouth moving, no words forthcoming. I was the car on the side of the road, transmission splattered on the asphalt. I was a clubbed fish, a wet finger in a socket. I was so beyond speechless, I was prehistoric. Australopithecus, Neanderthal. Homo incredulous. The head nurse, having emptied her quiver, retreated to more important matters. Trembling with a mixture of anger and befuddlement, I reached for the patient's chart and wrote orders to transfer him the hell out of the ICU. The hospitals in town have since combined, but at that time there were two. I resolved never to admit a patient again to that one if it was likely he'd need intensive care. And I didn't for some time. Eventually we got to know each other, and things smoothed out. The patient, I might add, continued on his trajectory and was discharged in record time.
In my opinion, ICU nurses are among the finest there are, and I've always gotten along with them -- more than got along: most were buddies. Their job is a really tough one, and a good ICU nurse is thing to be cherished, nurtured: nay, worshipped. Which, in general, I did. They came to me when they or their family needed surgery. But not that night nurse. Never saw her again. And my colleagues, whenever the opportunity presented itself, loved to regale me with "Our EVERETT physicians...."